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New Guidelines Help More ICU Patients Get Off Mechanical Ventilation

DETROIT – In one of the most common dilemmas facing the ICU, reducing the length of time patients are on mechanical ventilation decreases the risk of complications, but premature removal can produce different problems, including increased mortality.

That’s why the American College of Chest Physicians (CHEST) and the American Thoracic Society (ATS) have published new guidelines for discontinuing mechanical ventilation in critically ill adults.

Their goal is to help clinicians determine when patients with acute respiratory failure can breathe on their own and to provide clinical advice that might increase the chances for successful extubation. Background information provided by the groups notes that about 40% of all patients in the ICU are breathing with the help of a mechanical ventilator at any given time.

While that can be a live-saver, the downside is that mechanical ventilation can lead to complications, including infections and injury to the lungs and other organs, according to the report.

"Our guidelines committee wished to update the 2001 CHEST guideline concerning ventilator liberation, but we wished to do so by addressing new clinical questions. Our goal was to translate the latest findings into guidelines to improve patient care," explained co-lead author Daniel R. Ouellette, MD, FCCP, an associate professor of medicine at Henry Ford Hospital in Detroit. "These latest guidelines are informed by many studies published in the last 10 to 15 years that look at other factors that critical care clinicians control that affect a patient's ability to be liberated from the ventilator in a timely manner."

Here is a summary of the recommendations, based on a systematic review of medical studies, for acutely hospitalized adults on mechanical ventilation for more than 24 hours:

  • For patients at high risk for extubation failure who have passed a spontaneous breathing trial (SBT), guideline authors recommend extubation to preventive non-invasive ventilation (NIV). The committee found evidence that transitioning to non-invasive ventilation reduced ICU length of stay and short- and long-term mortality. NIV in these patients should begin immediately after extubation "to realize the outcome benefits,” the author wrote.
  • The initial SBT should be conducted with inspiratory pressure augmentation rather than T-piece or CPAP, according to the guidelines. The committee wrote that conducting the initial SBT with pressure augmentation was more likely to be successful, produces a higher rate of extubation success, and was associated with a trend toward lower ICU mortality.
  • Protocols attempting to minimize sedation also are suggested because those could reduce ICU length of stay, although sedation protocols did not appear to decrease time on the ventilator or reduce short-term mortality. No protocol was recommended over another.
  • Protocolized rehabilitation directed toward early mobilization also was advised. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital, although that did not appear to affect the mortality rate. Exercises created additional work for ICU staff that might have come at the expense of other care priorities, the authors pointed out.
  • Management of patients with a ventilator liberation protocol also was recommended by the committee, which stated that patients managed by protocol spent, on average, 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. Again, however, their mortality rate appeared unchanged.
  • A cuff leak test in patients who meet extubation criteria and are deemed at high risk for post-extubation stridor is advised by the committee. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.
  • For patients who failed the cuff leak test but are otherwise ready for extubation, the guidelines recommend administering systemic steroids at least four hours before extubation. The short duration of the steroid therapy was likely to improve success rates without resulting in adverse events, the committee pointed out.

"Our goal was not to prescribe approaches to care that should be applying without thought to every patient in every situation," added co-lead author Timothy Girard, MD, MSCI, associate professor of critical care medicine at the University of Pittsburgh. "Rather, we sought to summarize the best available evidence in a clear, succinct way so that clinicians know what the evidence says about how to liberate the majority of mechanically ventilated ICU patients quickly and safely."

Girard said that, with nearly every question the committee examined, “we found new evidence to guide clinical practice as well as a need for additional research."